Call for Nominations: Elder Caregiving Award

Since 1995, the Elder Caregiving Award has symbolically honored all Ohioans who lovingly care for family and friends by recognizing outstanding individuals who selflessly dedicate their lives to the care of others.?

Criteria:?

Caregiver or care recipient must be age 60 or older. Caregiving must not be job-related.
Caregiver or care recipient must be a current resident of Ohio.
Self-nominations will not be accepted.

To nominate someone for induction, simply complete and submit the form below. Alternately, you can download a printable nomination form to fill out and fax or mail in.

All fields, except where noted, are required.

For help completing this form, refer to the Additional Instructions and Information or click the ? icon for context-specific help.

Caregiver's name:?
Street address:
City, state, ZIP:
County:
Daytime phone:
Birthdate (mm/dd/yyyy):

Care recipient's name:?
Street address:
City, state, ZIP:
County:
Daytime Phone:
Birthdate:

How long has care been provided?

Nomination essay?

Describe the severity of the care recipient's condition:?

Describe the degree of difficulty of the care provided:?

Describe any unique or innovative approaches to caregiving:?

Describe special circumstances or barriers faced by the caregiver and how he or she is working to overcome them:?

Describe the impact of care provided on the recipient and his or her family:?

Describe the impact on the caregiver and his or her family:?

Describe the sources and types of care assistance provided by others or oganization:?

Nominator's name:?
Street address:
City, state, ZIP:
Daytime phone:
E-mail (optional):

By clicking the submit button below, you acknowledge that the information contained in this nomination is factual and accurate and that you have verified it with the nominee.? Nominations will only be accepted between Aug. 1 and Sept. 15, 2008. Please refer to our Privacy Statement for details about information sent electronically.

Additional Instructions and Information

Selection process - All eligible nominees will be evaluated by a selection committee using a formal rating system. To achieve statewide representation, the Ohio Department of Aging will select one Elder Caregiving Award recipient from each of twelve geographic regions of Ohio. Nominees will be evaluated with others in their region only and not compared on a statewide level. Click here for a map showing these regions.
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Minimum criteria - A nominee must meet all three criteria listed on this nomination form to be considered for the Elder Caregiving Award.
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Nominee information - Please provide all information requested. Birthdate information will be used to determine eligibility only and will be shared with the selection committee, but will not be published or shared with any other party or used for any other purpose without the nominee's consent.
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Care recipient information - Please provide all information requested. If the nominee provides care to more than one person, list the primary recipient on the form and provide the same information for others on a separate sheet. Birthdate information will be used to determine eligibility only and will be shared with the selection committee, but will not be published or shared with any other party or used for any other purpose without the nominee's consent.
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Length of care - If the nominee provides care to more than one person, list the primary recipient on the form and provide the same information for the others on a separate sheet.
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Essay - Your essay should be approximately 1,000 words total and must cover all of the description categories on this form.
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Severity of care recipient's condition - Without divulging personal medical details, explain how the care recipient's condition interferes with activities of daily living (e.g., dressing, bathing, grooming, eating, mobility, tec.). Describe the degree to which he or she is dependent on others.
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Degree of difficulty of care - Describe how hard it is for the nominee to provide care. Provide details of any training or specialized knowledge required.
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Unique or innovative approaches to caregiving - Describe ways the caregiver "thinks outside the box" to make his or her efforts easier for himself or herself or more beneficial to the recipient. Examples include technology, home modification, coordinating care among family members, etc.
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Special circumstances or barriers - Explain difficulties that interfere or could interfere with the provision of care and describe the nominee's approach to overcoming them. Examples include personal health, family situations, social pressures, financial limitations, etc.
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Impact on recipient and family - Describe how the care provided by the nominee enhances the recipient's overall quality of life, as well as that of the recipient's family.
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Impact on caregiver and family - Explain how caregiving duties and the efforts of the nominee affect his or her family, both positively and negatively.
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Care assistance provided by others - List the sources and types of assistance this nominee uses to support his or her efforts and describe how this assistance helps both the nominee and the recipient.
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Nominator information - Please provide your contact information. If you are nominating on behalf of an organization, please note so along with your name.
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Affidavit - By signing/submitting this nomination, you certify that the information it contains is accurate and has been verified by all appropriate parties, including the nominee and the care recipient.
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